What Will You Learn in Your Medical Billing Classes?

Get prepared by finding out exactly what you'll learn in your medical billing classes...

No matter which medical billing program you choose, the basics of learning medical billing remain the same.

Although this isn't a representation of actual medical billing programs or a course of study, your medical billing classes should all contain the fundamental elements of learning how to be a medical biller and work in a medical office setting.

Medical Billing Basics

Want to quickly get to grips with the fundamentals of medical billing? We recommend the ebook The Basics of Medical Billing, a guide to the industry written by a mother/daughter team of billers. Learn more about it here.

Coding

Even if you aren't going to be coding yourself, medical billing requires an understanding of the essential elements of coding.

In a typical medical setting there are three standardised code sets (ICD-9, CPT, and HCPCS Level II). These translate the patient visit into numbers, which are sent to patient insurance companies in claims for payment.

ICD-9 codes are the diagnosis codes, and contain from three to five numbers. In 2013, this entire code set is scheduled to change to the ICD-10 code set, which includes a more detailed and specific set of diagnosis codes.

CPT codes represent the procedures performed by the provider to the patient, on the date of service. They are typically five numbers long. These include everything from the physical examination to surgeries, and everything in between.

HCPCS Level II codes represent the supplies and services used in performing medical procedures. They are five digits long, and include one letter and four numbers. These include durable medical equipment, medicine codes, and ambulance or transportation codes.

If you're a medical biller, you'll not have to assign these codes. But you'll still need to understand them to make sure your claims are billed correctly.

Types of Providers

It's important to understand that there are many different types of providers. It's not technically correct to use the term "doctor" in every case - often patients aren't seen by doctors, but by mid-level providers.

This distinction is necessary because insurance companies usually pay less for care provided by Physician Assistants (PA) and Nurse Practitioners (NP).

Billing for NPs and PAs depends on your local state requirements. This is why you'll generally see the term "provider" or "practitioner" rather than "doctor."

Types of Payers

In your medical billing classes, you'll also learn that not all patients pay for their medical services the same way...

Self-pay patients: Patients without medical insurance are considered self-pay patients. They usually pay up front for their medical services, or work out a payment arrangement with the billing office.

This is where medical billers come in.

Many times, medical offices will help self-pay patients by giving them special discounts or extended payment plans, depending on the amount of money owed and procedures performed.

Commercial Insurance: The majority of patients in the medical industry have some sort of commercial insurance. This means that they pay a monthly premium to a private health insurance carrier, in return for payment on their medical claims.

Providers send claims to insurance companies, who review the claim and determine if it meets all the necessary requirements to make a payment.

Many commercial plans require some sort of patient co-payment, co-insurance, or deductible, which is a type of cost-sharing. In this case, the insurance company requires a small payment from the patient in addition to sending their payment on the claim.

Government Insurance: The United States government provides medical insurance to specified portions of the population, depending on their age and income level. There are different types of government insurance, the largest of which is Medicare.

Medicare is administered through the Centers for Medicare and Medicaid Services (CMS), which sets the standard for most insurance practices throughout the country, both government and commercial.

There are different types of Medicare, ranging from Type A to Type D. Each type includes coverage for specific types of medical claims. These range from coverage for prescription only, to doctor visits only, and to doctor plus hospital coverage. Medicaid is a type of Medicare that covers eligible children only.

You may have the option of taking medical billing classes on specific types of government coverage, which will help you learn more about this complicated topic.

RBRVS (Resource-Based Relative Value Scale)

Medicare payments for medical services are standardized using a scale of the typical work involved in medical treatments. This scale takes into account:

the provider's expense in providing the service

the malpractice insurance needed for the provider

and the facility expenses for each patient treatment.

These three factors are then multiplied by a scale which takes the provider's geographic location into account. This may increase or decrease the payment amount.

Although the RBRVS is implemented and developed by Medicare, many commercial payers also refer to the scale to regulate payment on procedure and supply codes.

This scale is updated regularly, to take into account increasing overhead and malpractice insurance costs as well as changes in geographic elements.

HIPAA

HIPAA, or the Health Insurance Portability and Accountability Act of 1996, was implemented to maintain the privacy and security of patient and insurance data in the electronic age.

Your medical billing classes should teach you the fundamental elements of HIPAA, and how they impact the daily workings of a medical practice.

Fraud and Abuse

An essential element of understanding medical billing is knowing what constitutes fraud and abuse.

The majority of fraud is begun on the medical coding side of the equation. It includes using elevated codes to get higher payment from the insurance carrier as well as billing for services that weren't rendered by the provider.

Fraud and abuse is a very serious concern, which is investigated by the government.